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Neurological Changes in the

Geriatric Patient

OhioHealth Grant Medical Center

LifeLink Winter Update 2014

Amanda Cramer MSN, RN, FNP-BC, CNRN

Family Practice Nurse Practitioner

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Objectives

• Review Neuro Anatomy

• Anatomic Changes in the Aging Patient

• Neuro Assessment Review

Neuro-Geriatric Review

• Neurological Disorders– Stroke

– Back Pain

– Neuro Trauma– Cognitive Disorders

– Other Neurological Disorders

• Neurologic Considerations in the Elderly

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Neuro Anatomy

• SCALP- Skin, SubCutaneous Tissue, Adipose Tissue, Ligament (Galea), Periosteum

• Menningies- Dura Mater Arachnoid Pia Mater

Brain Anatomy

Menningies- Dura Mater, Arachnoid, Pia Mater

• Neurons- Cell body, Axon, DendriteMyelin sheath

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Neuro Anatomy • Hemispheres

• Corpous callusom

• Cerebellum

• Diencephalonp

• Midbrain

• Pons

• Medulla Oblongata

• Spinal Cord

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Neuro Anatomy • Frontal Lobe

– Problem Solving, Emotion, Judgment, Creative Thought

– Broca’s Area (left frontal) Expressive language

• Parietal Lobes

– Tactile Sensation, ProprioceptionTactile Sensation, Proprioception

– Academic Skills

– Sensory Comprehension

• Occipital Lobe– Visual perception, Visual input, Reading

– The perception and recognition of printed words.

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• Temporal Lobes– Some hearing and vision

– Auditory and Visual Memories– Wernicke’s Area (left temporal)

Receptive language

• CerebellumCerebellum– Balance, Equilibrium,

Coordination of voluntary movement

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• The Ventricals- Lateral Ventricles, Third and Fourth Ventricle.

• Cerebrospinal fluid

Cerebral Spinal Fluid

Cerebrospinal fluid - CNS protection- Compensation- Nutrition

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• Circle of Willis

• Vertebrobasilar Arteries– Supply posterior circulation

Cerebral Blood Supply

– Through transverse processesof C5- C1

• Carotid Arteries

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Cranial Nerves

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Neuro Anatomy

• Vertebral Column- 33 Vertebrae– 7 Cervical (C1-C7)– 12 Thoracic (T1-T12)

Spine

( )– 5 Lumbar (L1-L5)– 5 Sacral (S1-S5)– 4 Coccygeal

• Anterior Longitudinal Ligament, Posterior Longitudinal Ligament

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• Extends from base of medulla to conusmedullaris (across from L1–L2)

• Surrounded by menningies

Spinal Cord

Surrounded by menningies

• CSF flows in the subarachnoid space

• Vascular supply Comes from branches of the Vertebral

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• 31 pairs along the length of the cord

• First 7 cervical pairs exit above corresponding

t b C8 it b l C7 t b

Spinal nerves

• vertebrae, C8 exits below C7 vertebrae

• All thoracic, lumbar, and sacral nerves exit below corresponding vertebrae

• Part of the Peripheral Nervous System

• Plexus – bundle of nerves join together

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Neuro Assessment

• Mental Status

• Cranial Nerves

• Proprioception

• Cerebellar Function

• Motor Function

• Sensory Function

• Reflex function

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Neuro Assessment

• Start with the least amount of stimuli

• Assess head to toe– Except spine injuries, assess strength/sensation toe-

to-head

• Proceed in a systematic approach• Proceed in a systematic approach

• Utilize standardized scales

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Mental Status • Level of Consciousness-

– One of the most sensitive parameters to neurologic changes

– Large deferential for mental status changes

• Glasgow Coma Scale (3-15)Glasgow Coma Scale (3 15)– Traditional Terms

• Alert, awake, lethargic, stuporous, semi-comatose, and comatose

• Level of consciousness- Check to Verbal, Visual, Tactile, Noxious, Painful

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Neuro Assessment

• Is the patient able to follow commands? Are they oriented to person, place, time and situation.

Mental Status

• Memory, intellectual performance, insight, problem solving.

• Affect and mood

• Communication- Aphasia, Receptive, Expressive, Dysarthria

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Neuro Assessment

Cranial Nerve Check

• Pupils- PERRLA, EOMI, Gaze

• Face symmetry and sensation

• Speech taste smell and hearing

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• Speech, taste, smell and hearing

• Tongue and palate movement

• Shoulder shrug

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Neuro AssessmentI - Olfactory nerve

II - Optic nerve

III - Oculomotor nerve

IV - Trochlear nerve

V - Trigeminal nerve/dentist nerve

VI - Abducens nerve

VII - Facial nerve

VIII - Vestibulocochlear nerve/Auditory nerve

IX - Glossopharyngeal nerve

X - Vagus nerve

XI - Accessory nerve/Spinal accessory nerve

XII - Hypoglossal nerve

* Mnemonic-

• On Old Olympus' Towering Top, A Friendly Viking Grew Vines And Hops

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Neuro Assessment

Muscle Strength

Drift

At i

Motor Exam

Ataxia

Gait

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Neuro Assessment

• Light touch

• Deep pain

T t

Sensation

• Temperature

• Vibration

• Proprioception

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Neuro Assessment

0 = no response

+1 = hypoactive

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Reflexes

Biceps (C5-6)Triceps (C6-8)Brachioradial

+2 = normal

+3 = brisk

+4 = hyperactive

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Quadriceps (L3-4)Patellar (L3-4)Achilles (S1-2)

Changes in the aging adult

• Hair loss on the scalp

• Eyes- decreased pupil size, presbyopia, cataract.

• Hearing loss.

• Diminished salivary secretions and taste. Tooth decay and loss.

• Brain atrophy

• Curve of the thoracic spine (kyphosis), loss of height, intervertebral disc thin and vertebral bodies shorten or collapse from OA.

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Changes in the older adult

• Decreased skeletal muscle bulk.

• Brain volume due to atrophy and number of cortical cells decrease

• May develop benign essential tremors

• Decreased reflexes• Decreased reflexes

• Elevation in systolic blood pressure- stiffening of the aorta and large arteries due to artherosclerosis

• Postural hypotension

• Pacemaker cells decline- increase abnormal heart rhythms

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Neuro Disorders

• Disruption in normal blood supply to the brain

• New terminology - “Brain Attack”

• Fourth most common cause of death in US

Stroke

Fourth most common cause of death in US

• Primary cause of adult disability in the US

• About 795,000 Americans each year suffer a new or recurrent stroke.

• On average, a stroke occurs every 40 seconds and every 4 minutes someone dies of stroke

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Stroke

• 80% of strokes

• Diminished blood supply to the brain

Ischemic Stroke

• Most common cause is thromboembolism

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• Left side stroke– Right visual field deficit– Right Hemiparesis

Ri ht H i

Stroke Symptoms

• Right side stroke– Left Hemi-attention– Left Visual Field Deficit

L ft H i i– Right Hemisensoryloss

– Aphasia

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– Left Hemiparesis– Left Hemisensory loss

Stroke

• Brief interruption in blood flow by a clot

• Symptoms are the same as stroke but last usually less than five minutes (one minute on average)

Transient Ischemic Attack

less than five minutes (one minute on average).

• No permanent brain injury

• 10% of strokes are preceded by a TIA.

• Also referred to as a “Mini-Stroke” or “Warning Stroke”

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Stroke

• A weakened vessel ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue.

Hemorrhagic Stroke

g– Intracerebral hemorrhage (within the brain): Most

common cause is chronic hypertension. – Subarachnoid hemorrhage (bleeding around the

brain): Most common cause is Aneurysm rupture

• Symptoms: Headache, N/V, Decreased LOC– SAH- stiff neck, light sensitivity– ICH- Focal Symptoms

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Stroke Assessment Tools Act FAST

Endorsed By the American Stroke Association

Used by first responders

Q i k A t T l Quick Assessment Tool-Easy to teach patients, families

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Face Drooping – Does one side of the face droop or is it numb? Ask the person to smile. Is the person's smile uneven?

Arm Weakness – Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?

Speech Difficulty Is speech slurred? Is the person unable toSpeech Difficulty – Is speech slurred? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence, like "The sky is blue." Is the sentence repeated correctly?

Time to call 9-1-1 – If someone shows any of these symptoms, even if the symptoms go away, call 9-1-1 and get the person to the hospital immediately. Check the time so you'll know when the first symptoms appeared

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TIME

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IS BRAIN

• Restore blood flow to the penumbra

• Stroke Prevention– Antiplatelet agent (ASA, clopidogrel, asa/dipyridamole

XR) Anticoagulant if indicated (warfarin)

Stroke Treatment Goals

XR), Anticoagulant if indicated (warfarin)

• Reduce modifiable risk factors– Hypertension, Smoking, Cholesterol, Glucose control,

CAD, Atrial Fibrillation, Obesity, Diet Control, Hypercoagulability

• Improve function- Physical, Occupational, Speech therapy. Physical Medicine and rehab

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Neuro Disorders

• Scalp Lacerations

• Subdural Hematoma

Sk ll/ F i l F t

Head Trauma

• Skull/ Facial Fractures

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Spine injuries

• Dislocation- vertabra overrides another- spinal cord may or may not be involved.

• Subluxation- partial or complete dislocation of one vertebra over another. Damage to the cord and supporting ligaments may be present.

H fl i F d t d i• Hyperflexion- Forward movement- wedge or compression fracture

• Hyperextension- Backward downward movement- whiplash. May see contusionj and ischemia of the cord. Stress at C4 and C5

• Compression Injury- Burst fracture, Wedge

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Spine Injuries

• Conditions causing back pain– Scoliosis/kyphosis– Neoplasms

Back Pain

p– Infections– Spondylosis– Osteoarthritis– Inflammation

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• Aging process- Decreased fluid content of nucleus pulposus

• Nucleus pulposus less elastic – tears

Degenerative disc disease

• Less effective shock absorbers

• Degeneration of posterior spinal ligaments

• Symptoms: Back pain with radiation to buttocks or thighs, often positional. Progressive, gradually onset.

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• Slipping or sliding associated with degenerative changes of the facet joints

• Anterior subluxation most common at L4/5

Lumbar Spondylolithesis

Anterior subluxation most common at L4/5

• Low back pain, vague, dull, achy. Often asymptomatic

• Positive straight leg raising (SLR)

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• Narrowing of the lumbar spinal canal

• Pain, numbness, or weakness with ambulation

• Walks farther with forward flexion support

Lumbar Stenosis

Walks farther with forward flexion support

• Bowel or bladder dysfunction

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• Due to bone weakened by osteoporosis, trauma, tumors

• Sudden onset severe pain reproducible on

Vetebral Compression Fracture

Sudden onset, severe pain, reproducible on palpation

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Neuro Disorders

• Spinal cord injuries-– Concussion- spinal shock or jarring causing

temporary loss of functionContusion bruising of the cord can cause bleeding

Spine Injuries

– Contusion- bruising of the cord, can cause bleeding, edema, necrosis, deficit depends on severity

– Laceration- Tear in the cord, can be complete of incomplete

– Transection: Severing of the cord– Hemorrhage: Bleeding into or around the cord

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Cognitive Disorders

Confused/perception disorder

Acute onsetReversible with treatment

Delirium

D- drugsE-electrolytesL-Low OxygenReversible with treatment

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L Low OxygenI- InjuryR- relapsing feverI-infectionU- uremiaM-metabolic

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Cognitive Disorders

D- DrugsE- EndocrineM- MetabolicE- EpilepsyN- NutritionT Tumor/Trauma

Dementia

Failing memory, personality changesChronic progressionAffects 7% of the population over the T- Tumor/Trauma

I- InfectionA- Arterial

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Affects 7% of the population over the age of 65

• Alzheimer disease • Non-Alzheimer-related• Parkinson disease with dementia

D ti ith L b di• Dementia with Lewy bodies• Fluctuating cognition, visual hallucinations, bradykinesia or rigidity, sleep

disturbances, frequent falls, syncope, orthostatic hypotension, urinary incontinence

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Neuro Disorders

• Movement Disorder

• Neuromuscular disorders

CNS i f ti

Other

• CNS infections

• Tumors

• Migraine

• Seizures

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Other Geriatric Considerations

• Pharmocokinetic changes – Muscle mass, %of body fat, kidney, liver function, GI

absorption

• Anatomic Changes

• Polypharmacology

• Living Will, Power of Attorney, Code Status

• Social Services

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Questions

Amanda Cramer MSN, RN, CNP, CNRN

Nurse Practitioner , Medical-Stroke Unit

Ohi H lth G t M di l C tOhioHealth Grant Medical Center

amanda.cramer1@ohiohealth.com

614-566-7606

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